XVII. European Stroke Conference
Nice, France

Poster Session: Challenging cases
 

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Subarachnoid haemorrhage in the Reversible Cerebral Vasoconstriction (Call-Fleming) syndrome: main features
R.R.Moustafa    C.M.Allen    J.-C. Baron                                                    
 
University of Cambridge/Addenbrooke's Hospital

UNITED KINGDOM

Background: The reversible cerebral segmental vasoconstriction (Call-Fleming) syndrome (RCVS) comprises acute severe recurrent (thunderclap) headaches, occasional transient or fluctuating neurological abnormalities, and reversible widespread segmental cerebral vasoconstriction. It is a benign condition with excellent prognosis, yet because it can be clinically and radiologically similar to a number of commonly encountered but more serious conditions, diagnostic difficulties may arise, leading to inappropriate and even potentially harmful investigative and therapeutic approaches. Subarachnoid haemorrhage (SAH) is a particularly misleading feature of the RCVS. Cases: We report three personal cases (all females, aged 33, 50 and 60 years) highlighting the occurrence of SAH as part of the RCVS. In all three patients, the SAH was of mild degree. In two patients with positive CT head, it was situated in one or two sulci in the upper cerebral convexity, an unusual location. Use of over-the-counter sympathomimetics and/or intense and abrupt major emotion with underlying labile arterial hypertension were the triggering factors. All three patients had typical angiographic features, and all made an uneventful recovery with no recurrence after up to 15 years follow-up. Comments: SAH is a not uncommon feature of the RCVS, occurring in ~25% of reported cases and may pose a diagnostic challenge. However, SAH sitting in a few convexity sulci should raise suspicion for the RCVS, which can then be confirmed by the typical angiographic appearances. Recognizing the spectrum of clinical features seen in RCVS, including particularly SAH, allows a sound approach to a safe diagnosis.

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
A rare case of basilar artery thrombosis and pontine haemorrhage
R. Sivakumar                                                                  
 
Ipswich Hospital, Ipswich, Suffolk

UNITED KINGDOM

Background: Dolichoectasia(DE) refers to a vascular anomaly when the blood vessels are elongated and dilated and vertebrobasilar arteries are more commonly affected. It is usually complicated by ischaemic stroke but bleeding can also occur. We present a very rare case when pontine haemorrhage occurred in the presence of basilar thrombosis which posed a challenge in the management. Case report: A 38 year old male was admitted with right sided limb weakness. He had been diagnosed to suffer from Dolichoectasia 10 years ago when he presented with left sided weakness. MRA done at that time also revealed basilar artery thrombosis and was commenced on warfarin. He had made a good recovery. During this admission CT scan revealed pontine haemorrhage and anticoagulation was discontinued. MRI and MRA were carried out and the latter revealed basilar artery thrombosis besides dolichoectatic vessels. Expansion of brainstem bleeds can have serious consequences but embolisation from a basilar artery thrombus is equally dangerous. In our patient, anticoagulation was withheld and it was planned to recommence anticoagulation after 3 weeks. However, in the third week prior to the commencement of anticoagulation, patient developed dysarthria and worsening of right sided weakness most likely due to an ischaemic event. CT scan brain revealed good resolution of pontine bleed and the patient was commenced on anticoagulation. The patient made a good recovery. Discussion: Haemorrhagic stroke in DE is associated with the degree of ectasia and elongation of the basilar artery and may be favored by use of anticoagulant agents.1 The co-existence of intraluminal thrombus and bleed pose a challenge. The management needs to be individualised. Ref: 1.Stroke. 2005;36:1421-25

http://www.eurostroke.org/ni_graphics/g_aid3057.htm
 

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Spinal subdural hematoma following intracranial hemorrhage due to cerebral venous thrombosis in a patient with polycythemia vera
G. Sirin    N. Yesilot    E. Ekizoglu     N. Keles     O. Coban    R. Tuncay     S. Bahar                     
 
Istanbul University, Istanbul Medical School, Edip Aktin Stroke Unit

TURKEY

Case Presentation: A 77 year old male presented with severe back pain and gait difficulty. History was remarkable for chronic alcohol abuse and daily 500mg ASA ingestion. Sudden onset of severe headache, nausea and vomiting followed by severe back pain within the first half- hour had occurred two weeks ago. In the following days headache subsided while back pain worsened and gait difficulty was noted. Cranial CT and MRI performed in the acute stage had shown intracerebral hematoma in the right temporal lobe extending to the adjacent subdural space. Neurological examination revealed meningeal irritation signs, bilateral Lasegue’s sign, bilateral papilledema, urinary retention and paraparesis without pyramidal findings. MRI of the lumbar and thoracic spine revealed subdural hematoma encompassing the whole lumbar region. Complete blood count showed leukocytosis, erythrocytosis and thrombocytosis leading to diagnosis of polycythemia vera, and hydroxyurea treatment was started. Neurological findings regressed over days but a generalized seizure occurred a month after presentation. CT and MRI showed thrombosis of the superior sagittal sinus and hemorrhagic infarction of the right frontoparietal upper convexity in addition to the previous findings. Cranial DSA showed thrombotic occlusion of the superior sagittal sinus and lateral sinuses bilaterally. In the second month left sided partial motor seizures and increased left hemiparesis was observed. Cranial MRI showed diffuse signal changes in the right hemispheric white matter, and anticoagulant therapy was started. Left hemiparesis and papilledema subsided over days and the patient remains stable 7 months later. Discussion: Spinal subdural hematoma is a rare condition usually related to trauma, spinal intervention, coagulopathy and vascular malformations. Spinal hematoma following intracranial hemorrhage is uncommon. To our knowledge, this is the first report of symptomatic spinal subdural hematoma as a complication of cerebral hemorrhagic venous infarction in a patient with myeloproliferative disease.

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Partially reversible posterior-predominant ‘cortical and subcortical encephalopathy’ secondary to giant cell arteritis
A.J.MacCarthy    J.A.Kinsella    R.P.Murphy     F.M.Brett     D.J.H.McCabe                                    
 
The Adelaide and Meath Hospital, Dublin, Incorporating the National Childrens Hospital,

IRELAND

Background: Reversible ‘cortical and subcortical encephalopathy’ involving the posterior and anterior circulation is not well described in giant cell arteritis. Case History: A 74 year old right handed man presented with an 11 month history of slowly progressive cognitive impairment, predominantly involving posterior cortical domains. One month after symptom onset, he experienced transient anorexia, weight loss and proximal myalgia. Uncontrolled generalised seizure activity prompted urgent admission, followed by a progressive severe global encephalopathy leading to a minimally responsive state. Investigations: Normocytic anaemia (11 g/dl), peak ESR 90 mm/hr, and CRP 51 mg/L (normal: 0-5), with normal haematological, biochemical and auto-antibody screening otherwise. T1-, T2-weighted, and FLAIR MRI of brain revealed confluent asymmetrical signal change in the occipital cortex and subcortical white matter, and parieto-temporal and frontal white matter with some appearances consistent with vasogenic oedema. Gradient-echo MRI revealed minimal microhaemorrhage formation. CSF examination revealed a protein of 60 mg/dl but was otherwise normal. Giant cell arteritis was confirmed by temporal artery biopsy. The patient responded dramatically to high dose steroid therapy. He continues to improve 9 months after commencing treatment and is functionally independent. Discussion: A posterior-predominant steroid-responsive encephalopathy may arise secondary to intracranial cerebrovascular involvement in giant cell arteritis.

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Rapid Autonomic Dysfunction as a Cause of Diffuse Reversible Ischemia in a Case of Listeria Rhomboencephalitis.
A. Pikula    A. Augustine    S. Frank                                                    
 
Boston Univeristy School of Medicine Department of Neurology

USA

Introduction: Listeria Rhomboencephilitis (LR) typically presents with non-specific headache, nausea, vomiting, and fever followed by progressive brainstem involvement. Respiratory depression and apnea are common, but autonomic dysfunction (AD) is extremely rare. In addition, AD has been observed in medullary strokes, but never described as a culprit of diffuse reversible ischemia. Methods: We present a case of LR with rapid autonomic dysfunction causing diffuse reversible ischemia. Results: An 80-year-old woman presented with 4 days of nausea, vomiting and fever followed by an acute L facial nerve palsy, dysarthria, dysphagia and gait ataxia. Brain MRI showed an enhancing L dorso-lateral pontomedullary lesion effacing the fourth ventricle. Blood cultures grew Gram + rods, confirmed to be Listeria monocytogenes. Despite antibiotics, she developed respiratory failure and required intubation. On day 7 she experienced intermittent episodes of apnea and AD. When systolic blood pressure (SBP) fluctuated from 80 mm Hg to 230 mm Hg in the span of minutes, she rapidly became quadriparetic and poorly responsive. Diffusion-weighted images (DWI) showed areas of restricted diffusion involving both posterior and anterior subcortical white matter and the splenium of the corpus callosum, with reduced apparent diffusion coefficient (ADC), suggestive of ischemia. With AD management, quadriparesis and mental status improved. One week later, repeat MRI showed resolution of DWI/ADC abnormalities, confirming a pattern of reversible ischemia. Conclusion: Theory of reversible ischemia suggests that with varied durations of impaired perfusion, ADC is initially reduced but with reperfusion it would recover. Lesions made to the nucleus tractus solitarius can cause baroreflex failure, resulting in dysregulation of sympathetic activity and rapid fluctuations in BP as in our patient. This case illustrates a typical LR with brainstem involvement, but also adds rapid autonomic dysfunction as a cause of reversible ischemia.

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Recurrent Cerebral Venous Thrombosis Revealing Paraneoplastic Angiitis in Hodgkin’s lymphoma: Successful Outcome with Rituximab.
S. Roggerone    A. Traverse-Glehen    F. Berger     G. Salles     H. Rousset    S. Cakmak     C. Ralea     L. Derex    P. Trouillas   N. Nighoghossian
 
Cerebrovascular Unit LYON

FRANCE

Objective: Recurrent cerebral venous thrombosis (CVT), as a manifestation of paraneoplastic angiitis and revealing of nodular lymphocyte predominant Hodgkin’s disease (NLPHD), is an extremely rare condition. A successful immunotherapeutic impact was observed with the use of rituximab. Design: Case report. Setting: Cerebrovascular Unit. Results: A 55-year-old man developed recurrent CVT despite efficacious anticoagulant therapy and subsequent stenting of the superior longitudinal sinus. Progressive neurological deterioration ensued and a body scan revealed axillary lymph nodes. Pathological analysis led to a diagnosis of NLPHD. Conventional angiography showed CVT and multiple arterial narrowings. A paraneoplastic primary cerebral angiitis with prominent venous structure involvement was suspected. Efficacious immunotherapy using rituximab and steroids provided dramatic recovery. Conclusion: CVT due to paraneoplastic cerebral angiitis is a rare condition and represents a new, very rare manifestation of nodular lymphocyte predominant Hodgkin’s disease. Efficacious treatment with monoclonal antibodies may reverse the course of this severe disease.

Session: Poster Session II
Date: Thursday 15 May 2008  
Time: 12:30 - 14:00
Room: Agora 3

  
Acute total occlusion of the left internal carotid and both femoral arteries from left atrial thrombus in rheumatic heart: Combined medical and surgical management A case report
M.M.Awadh    S.A.Ragab    M.A.Sherif     M.A.El-Rahman                                            
 
Ain Shams University, Cairo, Egypt

UNITED KINGDOM

Background: Total occlusion of internal carotid artery (ICA) is one of the major stroke presentations with grave outcome. Simultaneous acute embolization to both femoral arteries from uncontrolled cardiogenic source is life threatening in acute context. Choosing either aggressive or conventional lines of management has no evidence to support. Methods: A 49 year old lady with known rheumatic mitral stenosis, not on anticoagulation, was presented with 8 hours stuttering onset of aphasia and right sided weakness revealed to be due to left ICA total embolic occlusion with acute occlusion of both femoral arteries and uncontrolled AF. Included in our ongoing trial, she received 1500 mg single dose of Clopidogrel, followed next day by 75mg/day and full anticoagulation. Bilateral femoral embolectomy was done on day 3, right leg fasciotomy on day 5, and the left atrial thrombus was removed and synthetic mitral valve replaced by open heart surgery on day 22, all with no bleeding complications. Results: Patient was admitted in deep coma with NIH-SS 25, yet regained full consciousness on next day with NIH-SS 12. After both lower limb surgeries, she could walk independently with NIH-SS 6, discharged 1 month later with NIH-SS 2. Mild subconjunctival hemorrhage and hematuria were reported on the second day. Follow up MRI, MRA showed total occlusion of left ICA & MCA, with minor capsular infarction. 3 CT follow up were free. Transesophageal ECHO showed moderate mitral stenosis and a thrombus in the left atrium. Carotid duplex was repeated but showed complete occlusion of the left ICA till her discharge on oral anticoagulant. Discussion: High doses of Clopidogrel might have a promising role in aborting major strokes in evolution and peripheral embolization without serious bleeding.